FY 2017 Annual Performance Plan and Report - Goal 3 Objective E

Topics on this page: Goal 3. Objective E | Table of Related Performance Measures | Analysis of Results | Plans for the Future | FY 2014 Strategic Review Objective Progress Update Summary

---

Goal 3.  Objective E:  Reduce the occurrence of infectious diseases

Infectious diseases continue to be a significant health threat in the U.S. and around the world because of increased and rapid global travel, increased importation of foods, and increased resistance to available drugs.  Infectious diseases include vaccine-preventable diseases, foodborne illnesses; HIV and AIDS; and tuberculosis.  They also include infections acquired in healthcare settings and infections transmitted by animals and insects. 

HHS coordinates and encourages collaboration among the many federal agencies involved in vaccine and immunization activities.  CDC has primary responsibility for reducing the occurrence and spread of infectious diseases in the U.S. population.  CDC provides significant support to state and local governments; strengthens infectious disease surveillance, diagnosis, and treatment; and collaborates with federal and international partners to reduce the burden of infectious diseases throughout the world.  FDA and CDC work together to prevent and control foodborne illness outbreaks, and FDA works with international drug regulatory authorities to expedite the review of drugs used to combat infectious diseases.

Infectious diseases exact a significant toll on human life.  The prevention and reduction of infectious diseases is a priority for HHS, which is being achieved though the coordinated efforts of AHRQ, CDC, CMS, OASH, and other HHS experts.  Other HHS components and offices that contribute to combatting infectious diseases include ASPR, FDA, HRSA, IHS, NIH, and OGA.  HHS will use a variety of approaches to reduce the occurrence of infectious diseases.  The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 3.E Table of Related Performance Measures

Reducing foodborne illness in the population.  By December 31, 2013, decrease the rate of Salmonella Enteritidis (SE) illness in the population from 2.6 cases per 100,000 (2007-2009 baseline) to 2.1 cases per 100,000.  (Lead Agency - FDA; Measure ID - 212409)

Reducing foodborne illness in the population.  By December 31, 2017, working with federal, state, local, tribal, and industry partners, improve preventive controls in food production facilities and reduce the incidence rate (reported cases per 100,000 population per year) of Listeria monocytogenes (Lm) infections by 8 percent.  (Lead Agency - FDA; Measure ID - TBD)

Increase the percentage of adults aged 18 years and older who are vaccinated annually against seasonal influenza (Lead Agency - CDC; Measure ID - 1.3.3a)

Achieve and sustain immunization coverage in children 19 to 35 months of age for one dose of measles, mumps, and rubella (MMR) vaccine.  (Lead Agency - CDC; Measure ID - 1.2.1c)

Reduce the proportion of persons with an HIV diagnosis at later stages of disease within three months of diagnosis (Lead Agency - CDC; Measure ID - 2.1.8)

Increase the number of adults and children internationally with advanced HIV infection receiving antiretroviral therapy (ART).  (Lead Agency - CDC; Measure ID - 10.A.1.5)

Reduce the incidence (per 100,000 population) of healthcare-associated invasive Methicillin-resistant Staphylococcus aureus (MRSA) infections (Lead Agency - CDC; Measure ID - 3.3.2a)⁴

Reduce invasive healthcare-associated Methicillin-resistant Staphylococcus aureus (MRSA) infections. (Lead Agency - CDC; Measure ID - 3.3.2b)

Decrease the rate of cases of tuberculosis among U.S.-born persons (per 100,000 population).  (Lead Agency - CDC; Measure ID - 2.8.1)

American Indian and Alaska Native patients, aged 19-35 months, receive the following childhood immunizations: 4 DTaP (diphtheria, tetanus, and acellular pertussis); 3 IPV (polio); 1 MMR (measles, mumps, rubella); 3 or 4 Hib (Haemophilus influenzae type b); 3 HepB (hepatitis B); 1 Varicella (chicken pox); 4 Pneumococcal conjugate.  (Lead Agency - IHS; Measure ID - 24)

Analysis of Results

Salmonella is the leading known cause of bacterial foodborne illness and death in the United States.  Each year, food contaminated with Salmonella causes an estimated 1.2 million illnesses and between 400 and 500 deaths.  Salmonella Enteritidis (SE), a subtype of Salmonella, is the second most common type of Salmonella and accounts for approximately 20 percent of all Salmonella cases in humans.  The most significant sources of foodborne SE infections are shell eggs (FDA-regulated) and broiler chickens (USDA-regulated).  This challenges HHS’s ability to reduce Salmonella by limiting FDA’s regulatory authority over infection producing foods.  To attempt to decrease foodborne illness and death, the FDA and CDC have joined forces and made the reduction of SE infections attributable to shell eggs a Priority Goal for FY 2014 - 2015.  CDC reported that the illness rate during the 12-month period ending June 30, 2015 was 2.9 illnesses per 100,000.  This is a decrease from the 2010 rate (3.5 cases per 100,000) but is higher than the 2007-2009 baseline rate of 2.6 cases per 100,000 population. 

FDA’s new Agency Priority Goal to reduce foodborne illness is a long-term outcome goal that reflects FDA’s efforts, along with our partners in CDC and NIH, to decrease the rate of Listeria monocytogenes (L.m.).  Listeria monocytogenes infections are one of the leading causes of death from foodborne illness in the United States, resulting in an estimated 1,600 illnesses and 260 deaths each year.  With enactment of the 2011 Food Safety Modernization Act (FSMA), Congress mandated a paradigm shift to prevention – to establishing a modern system of food safety protection based not on reacting to problems, but on preventing them from happening in the first place.  Over the next two years, concentrated efforts to 1) improve preventative controls through inspections and technical guidance to industry, 2) improve surveillance and detection using whole genome sequencing of L.m. isolates, and 3) improve response by more accurately linking illnesses and outbreaks to the food that caused the illness, should lead to a reduction in the overall L.m. rate.

Influenza is another major public health problem in the United States and globally.  In the United States, on average 5-20 percent of the population contracts the flu, more than 200,000 people are hospitalized, and approximately 36,000 people die from seasonal flu-related causes.  In 2010, CDC’s Advisory Committee on Immunization Practices (ACIP) recommended the seasonal influenza vaccine for everyone 6 months of age and older.  In FY 2012 CDC revised its flu measure to reflect the CDC’s priorities to meet the new standards of vaccinations for everyone 6 months and older.  In FY 2014 the number of adults that received a flu vaccination increased to 44 percent, however CDC did not meet its goal.

CDC works to tackle the biggest health problems causing death and disability in America.  For young children this means promoting immunization coverage for recommended vaccines.  Prior to wide-spread immunization nearly all children in the U.S. came down with the measles and about 500 people a year would die, 48,000 would be hospitalized, 7,000 had seizures, and about 1,000 suffered permanent brain damage or deafness.  CDC exceeded its target in FY 2014 with 92 percent of children 19 to 35 months of age receiving MMR vaccination.

More than 1.1 million people in the United States are living with HIV infection, and almost 1 in 6 (15.8 percent) are unaware of their infection.  Prior to 2012, CDC tracked the percentage of people diagnosed with HIV infection at earlier stages of disease (not CDC stage 3: AIDS).  From 2007-2010, the percentage of people identified at earlier stages of disease steadily improved to almost 56 percent.  Per the HHS Secretary’s memo (April 2012) on implementing a common set of core indicators across federal agencies, CDC has revised this indicator definition to conform to a new cross–agency definition.  In FY 2013, 23.6% of persons diagnosed with HIV were diagnosed late in the course of infection, an improvement over 2012 results.  Internationally, CDC is also focused on providing life-saving ART to adults and children to help control the HIV epidemic.  In FY 2015, CDC collaborated with CDC supported partners in 23 PEPFAR countries to provide life-saving ART for 5,841,700 HIV-infected adults and children, about 61% of all ART provided by PEPFAR.  Over four million (4,041,000) of these individuals are receiving direct service delivery support and an additional 1,800,700 are benefiting from essential technical support provided by CDC.  This represents a 36% increase compared to FY 2014 in adults and children with advanced HIV infection receiving ART and a 43% increase compared to FY 2013.

In alignment with HHS National Action Plan to Prevent Healthcare-Associated Infections, CDC has developed guidelines and plans to reduce infections associated with healthcare settings, including but not limited to invasive Methicillin-resistant Staphylococcus Aureus (MRSA) infections.  In FY 2014, there were just over 55,000 cases of MRSA with an incidence of 17.30 per 100,000 population.  This represents a 36% decrease from 2007-2008 baseline.  CDC replaced Measure 3.3.2a with a more nationally representative measure in FY 2015.  This new measure is an estimate of the overall number of healthcare-associated MRSA bacteremia cases (healthcare onset and healthcare-associated community onset), the most common type of invasive MRSA infections in the U.S. Preliminary baseline data demonstrate 41,000 cases in 2015.

Another condition the CDC is actively addressing in a collaborative manner includes tuberculosis (TB).  Effective control efforts by CDC and its 68 state and local partners contributed to the lowest number of U.S. Tuberculosis (TB) cases since national reporting began in 1953.  Data indicate there were 9,421 TB cases in 2014, representing 3.0 per 100,000 population and 1.2 for U.S. born population, exceeding the target.  Reflecting program effectiveness, the United States consistently ranks among the lowest TB incidence countries in the world.

In other areas related to decreasing infectious diseases, IHS is measuring the percentage of American Indian and Alaska Native children 19 to 35 months of age receiving a combined series of immunizations consistent with the CDC’s Advisory Committee on Immunization Practices standards and schedule that includes coverage for diphtheria, tetanus, whooping cough, polio, measles, mumps and rubella, Hepatitis B, influenza, chicken pox and pneumonia.  The childhood combined immunization series was updated in FY 2013 in accordance with the revised Healthy People 2020 and CDC childhood immunization guidelines; therefore, subsequent results will differentiate the use of the 3 or 4 dose Hib vaccine for individual patients.  As a result of this change in immunization schedule, the FY 2013 result set a new baseline of 74.8 percent.  The FY 2015 result of 73.3% narrowly missed the target of 73.9%.

Plans for the Future

Because the current Priority Goal measure for reducing Salmonella Enteritidis (SE) infections includes all infections related to chickens, determining which infections are attributable to shell eggs (as opposed to broiler chickens) makes it difficult to determine whether the FDA’s egg rule is having the desired effect of reducing the likelihood that contaminated shell eggs are the cause for a particular infection.  CDC is working with FDA to explore the use of multiple statistical approaches to estimate source attribution.  In particular, CDC and FDA are working to obtain data suitable for a “food product” model used in other countries to link contamination rates in foods to illness incidence.  The FDA will continue inspections of large and small egg producers, while continuing to refine its egg rule enforcement policies with straightforward inspection, re-inspection, and warning strategies, aiming to reduce Salmonella Enteritidis infections each year through 2015.  CDC's efforts to improve adult influenza vaccination coverage rates include: increasing patient and provider education to improve demand implementing system changes in practitioner office settings to reduce missed opportunities for vaccinations enhancing evidence-based communication campaigns to increase public awareness about adult vaccines and recommendations expanding the reach of vaccination programs including new venues such as pharmacies and other retail clinics.  This effort toward Salmonella infection reduction ended as a Priority Goal in FY 2015 and will be replaced by a focus on Listeria infection reduction for the FY 2016 – 2017 foodborne illness Priority Goal.

 CDC will continue infection prevention and control efforts to reducing HAIs across healthcare settings, supporting national progress toward the HHS National Action Plan to Prevent Healthcare Associated Infections:  Roadmap to Elimination.  CDC continues to support PEPFAR’s Impact Action Agenda, which is driven by the need to do the right things in the right places at the right time.  In close alignment with the Office of the U. S. Global AIDS Coordinator (S/GAC) and other U.S. Government (USG) agencies collaborating in PEPFAR, CDC will maximize the impact of USG-supported ART programs worldwide by focusing resources in key geographic areas, reaching the most vulnerable populations, completing Site Improvement through Monitoring System (SIMS) assessments at all CDC-supported sites, and actively participating in the Interagency Collaboration for Program Improvement (ICPI).

The IHS supports the delivery of all routine childhood immunizations by providing clinical decision support and reminders for providers in the IHS Electronic Health Record.  For FY 2016, IHS will update the reminders as needed, and will provide at least 2 web-based trainings for providers on the rationale for and use of these reminders.  In addition, IHS will collect quarterly childhood immunization coverage reports in FY 2016 and disseminate coverage data to Area Immunization coordinators to identify sites with low coverage.  The Area Immunization Coordinators in each of the 12 IHS regions use these data to provide feedback to facilities and identify sites in need of additional assistance.  IHS will also continue to expand and support the electronic exchange of immunization data with state immunization information systems to support immunization efforts and continue to provide technical assistance and immunization education to IHS and tribal immunization programs.  Other IHS programs, such as Public Health Nursing, also support this measure by conducting outreach for maternal-child health initiatives including parenting education on childhood immunizations during postpartum visits.

FY 2014 Strategic Review Objective Progress Update Summary

Please note that this section summarizes the result of the FY 2014 HHS Strategic Review process, limiting the scope of content to that available prior to spring of 2015.  Due to this constraint, the following may not be the most current information available.

Conclusion:  Progressing

Analysis:  Infectious diseases response consumed significant HHS effort and resources in 2014.  At a time when MERS has replaced measles in the headlines and Ebola is just below the fold, review of HHS progress is timely and fraught with the enormity of the task.  Because infectious diseases know no borders the capabilities and capacity of local public health have a large impact on the occurrence of infectious diseases.  HHS works on many fronts to improve these capabilities globally.  Domestically, there is a disparity of state/local capacities and capability that alone and together impact the goal of reducing the occurrence of infectious diseases.

HHS’ impact on reducing the occurrence of variety of infectious diseases helps to illustrate progress on this objective.  For example, measles is a perfect indicator disease for the nation’s vaccine program.  While much attention was given to the outbreak of measles associated with Disneyland earlier this year as an indicator for the pockets of unimmunized children and adults in the country, had population immunity been significantly less, the outbreak would have been far more widespread and severe.  One lesson from the Disney-associated outbreak was that when many people are potentially exposed and need to be traced, it is an expensive and time-consuming process that diverts state and local health department resources from other priorities.  HHS staff played a significant role in the identification, containment, treatment and prevention of Ebola and Ebola Fighters were recognized as Time Magazine’s Person(s) of the Year.

The Department’s historic and continuing contributions to reducing HIV have contributed to the downward trajectory of the number of people who are dying from AIDS.  As President Obama said “This is a global fight and it’s one that America must continue to lead….no other country has done more that this country…  But we can’t be complacent,” PEPFAR’s impact far exceeds the reduction of suffering, death and despair caused by AIDS.  PEPFAR has built infrastructure, strengthened local health systems, and provided invaluable lessons and experience that will continue to inform and improve responses to unforeseen health crisis in the future.

HHS is working to address persistent challenges, especially in adult vaccination coverage, safe drinking water, and public health capacity.  Vaccination for seasonal influenza has improved, but not achieved desired levels.  Vaccination coverage levels among adults are low, and for those 65 and older the rate of vaccination has not substantially improved between 2000 and 2014.  Without concerted effort, especially given the aging of the US population, vaccine preventable disease in the adult population is unlikely to improve.  Approximately 13 percent of U.S. Households about 43 million people, use private drinking water systems that are unregulated under the federal Safe Drinking Water Act.  These systems are primarily private wells but may also include springs, cisterns, and hauled water systems.  From 1971 through 2006, there was significant increase in the annual outbreaks reported in individual water systems.  Public health resources are diminishing at multiple levels.  When state and local public health jobs are cut, the country loses important state and local capacity to track Healthcare Associated Infections or Antimicrobial Resistance, reduce our ability to assess prevention progress, provide infection control training, and effectively respond to outbreaks.  Staffing cuts also affect the capacity of public health laboratories to assist hospitals and test patient samples, and subsequently, the capacity of state and local public health to rapidly detect and respond to outbreaks.

A major area of effort for HHS will be the development of an Agency Priority Goal to combat antimicrobial resistance and including prevention activities related to antibiotic stewardship.  In terms of controlling the HIV epidemic, to the extent possible the Department will pivot to a data-driven approach, especially using sub-national and sub-population epidemiologic data that strategically targets geographic areas and populations where HIV/AIDS is most prevalent and has the greatest HIV incidence.

---